A woman's reproductive age is defined as being between 15 and 49 years of age and in 2017, there were 1.9 billion women of reproductive age in the world (World Health Organization (WHO), 2020).
Conception is defined as the successful fertilisation of ova by spermatozoa. According to the WHO, successful use of contraception enables women to determine how and when they want to have children. In healthcare practice this is usually referred to as ‘family planning’. Worldwide, the number of women using modern contraception has increased, rising from 73.6% in 2000 to 76.8 % in 2020, equating to over 842 million women (WHO, 2020).
Contraception works in the following variety of ways (NHS Inform, 2022):
There are multiple forms of contraception available in the UK; however, the only one that can prevent both pregnancy and the transmission of sexually transmitted infections is the condom (WHO, 2020; NHS Inform, 2022). The most popular form of contraception in the UK overall continues to be the oral contraceptive pill. However, there has been an increase in the use of long-acting reversible contraceptives (LARCs), with intrauterine devices becoming more popular in women over the age of 35 years (NHS Digital, 2022).
It may be that the longer-acting properties of this group of contraceptives are a more attractive proposition due to the longer periods between administration and being less prone to user error (National Institute for Health and Care Excellence (NICE), 2022a).
Assessing a patient for contraception: general principles
Discussing contraception can be an emotive issue for certain patient groups, and health professionals need to be supportive of women's personal and religious beliefs, and mindful of the terminology they use during consultations.
It is good practice to ask how patients identify their gender and to be clear on the pronouns they prefer (as certain patients may be trans or non-binary). This is clinically relevant, as combined hormonal methods should not be prescribed for trans men and non-binary people who are taking testosterone. This does not apply to other methods (Faculty of Sexual and Reproductive Healthcare (FSRH), 2017a; British Association of Sexual Health and HIV (BASHH), 2019).
Screening a woman for combined hormonal contraception, progestogen-only contraception, or intrauterine contraception should always be undertaken using the UK medical eligibility criteria for contraceptive use (FSRH, 2016).
Recommendations are presented using categories of safety, from Category 1 where there is no restriction for use to Category 4 where there is an unacceptable health risk. Ideally, the structure of a contraception consultation should include the following principles of discussion and assessment (NICE, 2022a):
Before prescribing contraception, it is important to discuss (NICE, 2022a):
Managing lifestyle factors
It is important that a holistic outlook is employed during any consultation and to make use of opportunities to discuss improvement of general health. Lifestyle factors that may be relevant to contraceptive prescribing include (NICE, 2022a):
Once a contraceptive is chosen, information (written if possible) should be provided on the following areas (FSRH, 2019a):
What to consider when prescribing contraception in women over 40
Risks in pregnancy
Women aged 40 years and over should be advised that there is a higher risk of maternal mortality, neonatal and maternal abnormality and loss, making pregnancy potentially dangerous for both mother and baby (FSRH, 2019a; MBRRACE UK, 2021).
In 2019, the number of women over 40 years becoming pregnant increased for the second year in a row, and Office for National Statistics (2020) data showed that 34% of pregnancies in women over 40 years ended in termination. Thus, it is important to explain the risks of becoming pregnant in this age group so that an informed choice can be made, and the physical and psychological trauma that may be involved with terminating an unwanted pregnancy can be avoided.
Perimenopause and menopause
Menopause refers to the time at which menstruation stops, caused by the loss of ovarian follicular activity. Menopause is clinically confirmed after 1 year of amenorrhea. For most women, menopause occurs between the age of 45 and 55 years and, in the UK, the mean age for menopause is 51 years (NICE, 2015; FSRH, 2019). The time before menopause is known as perimenopause. During perimenopause, menstrual frequency and flow may become less predictable and/or heavy (known as heavy menstrual bleeding) (NICE, 2022b).
Menopause is associated with multiple symptoms; for example, those that affect mood and the urogenital, vasomotor and muscular systems, and some of these symptoms may present in perimenopause (Baldwin and Jensen, 2013; NICE, 2015; 2022b). While contraception does not affect the course of a woman's menopause, it may mask the symptoms of perimenopause or the beginning of menopause (FSRH, 2019a). Where symptoms are exhibited during the expected age range (over 45 years), serum follicle-stimulating hormone (FSH) measurements are not recommended, and diagnosis should be based on symptoms (NICE, 2022b).
FSH measurements may be used to check menopause status for women over 50 years who are using progestogen-only contraception if required, or for younger women, or those with atypical presentation to confirm menopause. FSH measurements are not recommended in women taking combined hormonal contraception or hormone replacement therapy (HRT), as suppressed levels of estradiol and gonadotrophins can make results inaccurate (FSRH, 2019a; NICE, 2022b).
Early menopause is determined as occurring between the age of 40 and 45 years (following the exclusion of secondary causes). Specific health risks are linked to early menopause, including an increased risk of coronary vascular disease, which may be relevant when prescribing certain contraceptive methods (NICE, 2015; 2022b).
Despite a decline in fertility, which occurs naturally with age (particularly over 40 years), and the rarity of naturally occurring pregnancy over 50 years, there is still a continued risk of pregnancy until menopause (NICE, 2022a). Contraception is not required over the age of 55 years in women who are still experiencing menstruation, as natural conception is unlikely. However, some women may still wish to continue contraception for personal reasons, and this should be discussed (FSRH, 2019a).
Hormone replacement therapy and contraception
Unless there are safety implications, such as an increased cardiovascular risk, all methods of contraception can be considered in perimenopausal women, including combined hormonal contraception (CHC), which includes the combined oral contraceptive (COC) pill, patch and vaginal ring (NICE, 2022a). As pregnancy risk lowers with age, some women may prefer to switch to a non-hormonal method of contraception, such as condoms. For women experiencing perimenopausal symptoms, some contraceptive methods may manage these better than others, and may be useful alternatives to HRT (FSRH, 2019a; NICE, 2022b).
CHCs may be useful for women under 50 years as an alternative to HRT in managing symptoms, particularly when use is extended or continuous (no hormone-free break), which is an off-license indication (FSRH, 2019a; NICE, 2022b). While making lifestyle adaptations and using non-hormonal methods may be sufficient to manage some menopausal symptoms, HRT is the viable treatment option for many women (Table 1). HRT is prescribed as either a combination of oestrogen and progestogen, or as oestrogen alone.
| Contraceptive method | Safety with HRT | Role in HRT Women aged <50 | Women aged >50 |
|---|---|---|---|
| Mirena 52mg levonorgestrel intrauterine system (LNG-IUS) | Safe to use as contraception alongside estrogen of choice | Mirena is licensed for endometrial protection when combined with estrogen. It is currently the only LNG-IUS approved for this purpose |
|
| Progesteron-only injectable (DMPA) | Safe to use as contraception alongside sequential HRT but consider change to lower-dose progesteron-only method | Highly likely to be effective for endometrial protection with estrogen as part of HRT but cannot be recommended as unlicensed for this indication | |
| Progesteron-only implant (IMP) | Safe to use as contraception alongside sequential HRT | Cannot be recommended at the present time for endometrial protection as part of HRT as no evidence to support efficacy | |
| Progesteron-only pill (POP) | Safe to use as contraception alongside sequential HRT | Cannot be recommended at the present time for endometrial protection as part of HRT as no evidence to support efficacy | |
| Combined hormonal contraception | Do not use in combination with HRT | Can be used in eligible women <50 as an alternative to HRT | Women should be advised to switch to a progesteron-only method of contraception at age 50; see above for alternative options as they relate to HRT |
HRT prescribing should be guided by the following (NICE, 2015; 2022c):
The progestogen-only pill (POP), like the progestogen-only implant (IMP) and depot medroxyprogesterone acetate (DMPA) are not licensed for use as endometrial protection with oestrogen-only HRT. However, all progestogen-only methods of contraception may be used with sequential HRT (FRSH, 2019a). Postmenopausal women should be advised that they do not need to use contraception alongside HRT. If bleeding occurs in postmenopausal women using cyclical HRT, reassurance should be given that pregnancy will not occur (FSRH, 2019a).
Which contraceptive is best for women over 40?
For the advantages, disadvantages and failure rates of contraceptive methods in perimenopausal women see Table 2 (Bakour et al, 2017). Some forms of contraception can be continued and potentially extended until menopause, which may be a good option for women who would prefer to continue using their current ‘tried and tested’ method.
| Method | Advantages | Disadvantages | Risk of failure in first year of typical nonperfect use (%) |
|---|---|---|---|
| Combined hormonal contraception | Regular bleeding pattern Reduction in menstrual bleeding and flushes | Increased risk of thrombosis and breast and cervical cancer Daily dosing required | 9.0 |
| Progesteron-only pills | Very few medical contraindications | Irregular bleeding Daily dosing required | 9.0 |
| Progesteron-only injectable | Long-acting method Often induces amenorrhoea | Masks menopause Bone mineral density concerns Unable to remove after injection | 6.0 |
| Progesteron-only implant | Very few contraindications Easily reversible | Irregular bleeding Requires trained operative | 0.05 |
| Copper intrauterine device | Hormone free Does not mask menopause Long-acting method | Heavy menstrual bleeding and pelvic cramps Unsuitable if woman has a distorted uterine cavity | 0.8 |
| Levonorgestrelreleasing device | Long-acting method Treatment for heavy menstrual bleeding Endometrial protection with HRT | Irregular bleeding Unsuitable if woman has a distorted uterine cavity | 0.2 |
Recommended use of hormonal contraception (and intrauterine devices) is usually divided by age into the following groups: 40–50 years and over 50 years. Many forms of contraception can potentially be used until age 55 years (Table 3). For trans men and non-binary people, progestogen-only methods, intrauterine systems and the intrauterine device can all be used (BASHH, 2019). While some contraceptives may confer health benefits, some come with additional health risks.
| Contraceptive method | Women aged 40–50 | Women aged ≥50 |
|---|---|---|
| Non-hormonal | Stop contraception after 2 years of amenorrhoea | Stop contraception after 1 year of amenorrhoea |
| Combined hormonal contraception | Can be continued | Stop at age 50 and switch to a non-hormonal method or IMP/POP/LNG-IUS, then follow appropriate advice |
| Progesteron-only injectable (DMPA) | Can be continued | Women aged ≥50 should be counselled regarding switching to alternative methods, then follow appropriate advice |
| Progesteron-only implant (IMP) | Can be continued to age 50 and beyond | Stop at age 55 when natural loss of fertility can be assumed for most women |
| Progesteron-only pill (POP) |
|
|
| A Mirena LNG-IUS inserted ≥45 can remain in place until age 55 if used for contracpetion or heavy menstrual bleeding |
For women over 40 years, the following risks are increased:
Contraceptive methods: hormonal and intrauterine contraception
Intrauterine contraception
The two methods of intrauterine contraception (IUC) available in the UK are the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (Cu-IUD). Both are LARCs. Before IUCs are inserted a full assessment is required, which excludes pregnancy and STI risk. In general, IUCs should be removed following menopause (and at age 55 years) as they can cause infection if left in situ (NICE, 2022d).
There are three intrauterine systems available in the UK: Mirena, Levosert and Jaydess. Mirena is licensed for contraceptive use for 5 years, and Levosert and Jaydess for 3 years (FSRH, 2015; NICE, 2022d; FPA, 2020a). The 52 mg LNG-IUS may be useful for symptomatic treatment for women with heavy or erratic menstrual blood loss, as it may cause amenorrhea (FSRH, 2019a).
Mirena 52mg levonorgestrel intrauterine system may be used for contraception purposes until the age of 55 years if inserted at age 45 years or over. It can also be used for endometrial protection as part of an HRT regimen when combined with oestrogen and is the only LNG-IUS licensed for this. While it is only licensed for use for 4 years with HRT, it can be used for up to 5 years off label; however, the device must be changed every 5 years (FSRH, 2019a).
The Cu-IUD is a safe and effective choice of contraceptive (and emergency contraception) and is particularly useful for women with additional comorbidities for whom hormonal methods of contraception cannot be safely used. Use can be extended until menopause if it has been inserted after the age of 40 years (FSRH, 2014; 2019a).
Progestogen-only methods of contraception
There are three progestogen-only methods available in the UK: the POP, the implant (IMP) and the injectable (POI) (FSRH, 2014; 2019b; 2021; NICE, 2022d). The POP and IMP are not associated with increased risks of VTE, stroke or MI and have not been shown to adversely affect bone mineral density (Mantha et al, 2012).
Progestogen-only pills
There are several POPs licensed in the UK. Formulations include levonorgestrel, norethisterone, desogestrel, or drospirenone (FSRH, 2019b; NICE, 2022d). POPs can be used up to age 55 years and are a viable alternative to COCs for many women who prefer an oral method of contraception. They are also a useful substitution for women who have additional risk factors such as smoking or migraine (Nappi et al, 2013).
Progestogen-only injectables
Three injectable contraceptives are available in the UK: Depo-Provera, Sayana Press (both containing medroxyprogesterone) and Noristerat (norethisterone enantate) (FSRH, 2014; FPA, 2020a). Amenorrhoea affects up to 50% of women after 1 year of use of certain POIs, which may be a useful side effect for those who experience bleeding irregularities (FSRH, 2019a).
For women over 40 years there is a risk of reduction in bone mineral density due to the hypoestrogenic effects of depot medroxyprogesterone acetate.
Regular patient review and discussion regarding changing to an alternative contraceptive method is recommended, more so where there is an increased risk of osteoporosis due to additional reasons such as smoking or inactivity (FSRH, 2014). Women over 50 years should be counselled about changing to an alternative method (FSRH, 2014; 2019a).
Progestogen-only implant
Nexplanon is the only IMP available in the UK and contains etonogestrel 68 mg. The IMP should be replaced every 3 years. IMPs can cause amenorrhea, which may suit some, but it can also cause irregular bleeding – an undesirable outcome in a patient group who may already be experiencing this issue (FSRH, 2021; NICE, 2022d).
Combined hormonal contraception
In the UK the following CHCs are available:
CHCs can be used up to the age of 50 years, but women aged 35 and over who smoke have an increased mortality risk and should be advised to switch to an alternative method, such as the POP or an IUS (FRSH, 2019a).
Women over 40 years are prone to menstrual problems, and CHCs can help to reduce menstrual bleeding and pain, so may be useful for the under 50s who are unable to take HRT. Where irregular bleeding during the hormone-free break occurs, the use of continuous or extended dosing (not having a hormone-free break) may be useful to help manage this (off-license indication) (FRSH, 2019a; FPA, 2020a).
CHC use is associated with an increased risk of VTE, which is variable depending on the dose and type of progestogen used, and potentially the product (Weill et al, 2016). For the COC, the risk overall continues to be small and is highest when the COC is first started, or when restarted after a 1-month break (FSRH, 2019b).
COCs containing levonorgestrel or norethisterone, which have a lower dose of oestrogen (less than ≤30mg ethinylestradiol) may be more advantageous and are advocated as first line in women aged over 40 years due to the lower potential risk of VTE (FRSH, 2019a; 2019b). CHC use may offer a reduced risk of ovarian, endometrial and colorectal cancer, and in some cancers this protection may continue for many years after use has been stopped. CHC may also confer support in terms of bone mineral density in perimenopause (FRSH, 2019a; 2019b).
Emergency contraception in women over 40
Emergency contraception (EC) is used to prevent unintended pregnancy, when either unprotected sexual intercourse has occurred or where there has been contraceptive failure for varying reasons (WHO, 2021). In the UK, all three licensed forms of EC can be used in perimenopausal women (FSRH, 2017; FPA, 2020b). These are:
Conclusions
Helping a woman to choose an appropriate form of contraception that suits her lifestyle, age, medical history, personal beliefs and future pregnancy plans can be difficult, and special consideration is needed for women over 40 years whose requirements may be more complex than younger women.
The main considerations for women in this age group are the changes that occur to the menstrual cycle, including heavy menstrual bleeding, timing irregularities and perimenopause and menopause. Determining how to provide contraception that is both effective and safe, and does not cause additional side effects or interact with HRT, is a challenge. As a practitioner in this area, maintaining a contemporary knowledge of contraception for this patient group is not only a professional requirement but is an essential component of reflective practice and continued personal development. People are much more ‘information aware’ now due to the multiple data avenues available to them; and practitioners need to use contemporary contraceptive guidance to support and promote collaborative dialogue with their patients.
Useful resources
Brook www.brook.org.uk
Family Planning Association www.fpa.org.uk/professionals/resources
Faculty of Sexual and Reproductive Healthcare www.fsrh.org
NHS contraception guidance www.nhs.uk/conditions/contraception
National Institute for Health and Care Excellence Menopause: diagnosis and management www.nice.org.uk/guidance/ng23
National Institute for Health and Care Excellence Clinical Knowledge Summaries https://cks.nice.org.uk
Sexwise (website produced by the Family Planning Association for the National Health Promotion Programme for Sexual Health and Reproductive Health) www.sexwise.org.uk